DELAYED

—AND—

Non-Union of Fractures.

N, SENN, M. D.,MILWAUKEE, WIS.

[Abstract of a Lecture delivered to the Rock River MedicalSociety, at the Milwaukee Meeting, September 5,1883.]

[Reprinted from the “Weekly Medical Review ” ofSeptember 29, 1883.]

Published by J. H. Chambers & Co ,

Chicago, 111., and St. Louis, Mo.

DELAYED

—AND—

Non-Union of Fractures,

By N. SENN, M. D.,MILWAUKEE, WIS.

[Abstract of a Lecture delivered to the Rock River MedicalSociety, at the Milwaukee Meeting, September 5,1883.]

[Reprinted from the “Weekly Medical Review ” ofSeptember 29, 1883.]

Published by J. H. Chambers & Co.,Chicago, 111., and St. Louis, Mo.

DELAYED AND NON-UNION OF FBAC-TUBES.

N, SENN, M.8., MILWAUKEE, WIS.

The study and management of fractures havealways constituted interesting topics to the generalpractitioner. Fractures are of frequent occurrencein every community, and every physician is ex-pected to exercise ordinary skill in their treatment.In assuming the treatment of a fractured limb wealso assume grave responsibilities in law and equity,which demand of us the exercise of diligence andat least ordinary skill.

In civilcourts negligence on the part of the attend-ant has, and ought to have, no defense. The medi-co-legal responsibility of the surgeon is only too fre-quently made the subject of litigation in the classof injuries embraced in the subject now under con-sideration. It is a well known fact that manycases of delayed and non-union are made the basisfor mal-practice suits, wherein, on the part of theprosecution, the defendant in technical languageis made to answer to a charge of ignorance orneg-ligence irrespective of the cause or causes whichmay have prevented the ideal result in these cases—bony consolidation with fragments in good posi-tion. In all these cases the defendant labors undergreat disadvantages in court, inasmuch as the pop-ular idea is prevalent everywhere, that a brokenbone once properly set must unite by bone, and ingood position. The layman is ever ready to admirebone-setting as a great art, but can never be made

4

to comprehend the difficulties encountered in manycases in maintaining the fragments in constant, un-interrupted apposition. Before considering the con-ditions which may give rise to delayed or non-union, it may be well to refer briefly to the pro-cesses which nature employs in uniting a brokenbone. The process of repair after fractures hasfor centuries been a favorite subject for study, ex-periment and investigation on the part of the mostdistinguished surgeons and pathologists. Galenregarded callus as a substance thrown out aboutthe seat of fracture for the purpose of cementingthe ends of the broken bone together, withouthowever being capable of conversion into bone.This doctrine met with no opposition until YanSwieten asserted that the new material in the courseof time is transformed into bone.

J. L. Petit taught that bone-injuries are repairedin a manner similar to injuries of soft tissue, theprocess in bone being modified only by the densityof its own tissue. Duhamel-du-Monceau recog-nized the bone-producing function of the perios-teum and endosteum, while Haller looked upon cal-lus as the product of the fractured ends of thebones themselves, more especially the myeloid tis-sue. Dupuytren introduced the terms provisionaland definitive callus, attributing the formation ofthe former to the periosteum and soft tissue aroundthe seat of fracture, while the latter is the productof the bone-producing function of the bone andmarrow. He made the important and practical ob-servation, that the definitive callus does not makeits appearance until four to five months after theinjury, and that its completionrequires from eightto twelve months.

Bransby B. Cooper associated the formation ofcallus with inflammation, believing that it is theconjoined product of all the inflamed tissues in thefractured ends of the broken bone. Lambron ad-vocated the possibility of primary union between

5

the bone-ends under certain favorable circum-stances, through the medium of an interfragment-ary callus independently of the existence of a pro-visional callus. Yirchow, Eokitansky, Gegenbauerand Hein regard the connective tissue in bone, peri-osteum and adjacent soft parts as the most impor-tant and essential osteo-genetic structure. Hof-mokl classifies the tissues from which callus isproduced in the following order: periosteum, mar-row, bone.

Rigal and Vignal, in a series of well conductedexperiments, have carefully studied the influence ofthe circulation on the formation of callus.

The following is a summary of their conclusions:If periosteum is exposed to a moderate degree ofirritation, new bone is produced from the marrowbeneath the point of irritation without passingthrough the stage of cartilage. If irritation is in-creased, by displacing the fragments and rubbingthe soft parts, the result is cartilage beneath theperiosteum, which is subsequently converted intobone. To prove that bones can unite without peri-osteum, they removed a cylindrical piece of perios-teum from a long bone in an animal. After thewound had completely healed, the bone was frac-tured at the point where it had been denuded of itsperiosteum. The fracture united by bone after theusual time.

[The histology and formation of callus were il-lustrated by diagrams on theblack-board.]

It is no longer necessary to make a distinctionbetween provisional or temporary, and definitiveor permanent callus, as they are both the productof bone-producing tissue, and assist in the restora-tion of the continuity of the broken bone. A frac-ture may heal perfectly without the formation ofprovisional callus, and on the other hand the tissueswhich were supposed to furnish the provisional cal-lus may, under certain circumstances, furnish a per-manent callus.

6

The amount of callus thrown out in every in-stance depends on: 1, The general condition ofthe patient. 2. The location and structure of thefractured bone. 3. The amount of local injury.4. The degree of displacement. 5. The perfectionof immobilization.

As a rule, a minimum amount of callus is pro-duced when the patient is suffering from any wast-ing or acute febrile affection, or is the victim ofany so-called constitutional diseases; when thebroken bone is very compact and located near thesurface of the body; when the injury was slightwith little or no displacement, and when duringtreatment the broken ends have been kept at restand in constant and in uninterrupted co-aptation.

Opposite conditions are followed byan exuberantproduction of callus. The influence exercised bypara-periosteal tissues in determining the amountof callus is well illustrated in fractures of thetibia and ulna; where the bone is subcutaneous lit-tle or no callus is found, while in places where it isdeeply covered by muscular and aponeurotic tissuethe amount of callus is great, in some instances sogreat that it fills the entire inter-osseous space,forming abridge of bone across it, permanently ce-menting the fibula or radius, as the case may be, tothe broken bone.

T© obtain bony consolidation after a fracture cer-tain well recognized conditions are necessary; 1.A sufficient blood-supply to the part. 2. Unim-paired innervation of the part. 3. Placing andmaintaining the fragments in contact, or at least insuch close proximity that the callus thrown outfrom both extremities can meet and establish abony bridge between. Injury of any principal ves-sel or nerve of a limb, as a complication of anyfracture, does not only endanger the integrity ofthe limb but may constitute an important elementin the production of non-union.

Injury of the nutrient vessels of long bones has

7

no influence in determining non-union, as has beenclaimed by several writers, inasmuch as the com-bined statistics from the practice of different sur-geons do not sustain this assertion. An excessivesupply of blood in the part—either froman undue af-flux of blood, the consequence of an excessive irrita-tion about the seat of fracture, or from obstructionto the venous return—frequently affects callus for-mation in a detrimental manner. These conditionsoften interfere with the normal reparative process,the histological elements which are intended to fur-nish the callus not undergoing the typical embry-onal tissue transformation.

That an opposite condition may also unfavorablyinfluence callus formation was demonstrated to meplainly during the treatment of the following case:

Case I. Very oblique fracture of leg at the junc-tion of the middle with the lower third; delayedunion. C. L., set. forty, was treated at the Milwau-kee Hospital. The fracture was caused by directviolence. The sharp point of the upper fragmentshowed a strong tendency to project forward,whichcould not be overcome by any of the ordinary ap-pliances. Extension in the straight position wastried with no better results. At last I applied aYolkmann’s railroad splint, and placed the limbupon a steep single inclined plane, using extensionby a heavy weight at the same time, which finallysucceeded in keeping the bones in good position.It became apparent that very little callus formed,and four months after the injury, on careful exam-ination, I found free motionbetween the fragments.I became alarmed at the prospect of getting a falsejoint, and determined to secure bony union, ifneed be at the expense of considerable deformity.I applied a plaster of Paris splint and allowed thepatient to leave the bed and walk on crutches. Cal-lus appeared promptly, and in two months morebony union had taken place, of course with someprojection of the upper fragment forward.

8

Prolonged elevation then of a limb after fracture,by diminishing the blood-supply, may constitute acause of delayedor non-union, and I have since beencareful not to continue this position for too long atime.

The first step towards repair of a fracture is anosteo-plastic inflammation of the fractured ends ofthe bone. The vessels increase in size and num-ber, and the medullary tissue in the central canaland the medullary spaces in bone proliferates, itshistological elements being converted directly intobone bydeposition of the inorganic salts.

Ossification of the medullary tissue obliteratesthe medullary cavity for some distance at the end ofboth fragments; the canal is,however, invariably re-stored, after union has taken place, by a slow pro-cess of absorption. The callus from the surface ofthe fractured ends, the intermediate callus as it issometimes called, is slow in its appearance, butis usually directly transformed into bone, and isintended for the material utilized in the ultimaterestoration of the continuity of the bone. Natureusually supplies a surplus' of callus, which is grad-ually removed by absorption as soon as firm unionhas taken place, but which for the time being an-swers an exceedingly useful purpose in immobili-zing the fragments.

The time required for bony consolidation to takeplace varies in different individuals and underdiverse circumstances. All conditions which facili-tate a prompt formation of callus, and at the sametimereduce the amount to the minimum requisite,ai‘e instrumental in hastening bony consolidation.The time necessary for firm union to take place isusually longer than we have been taught. Accord-ing to Gurlt the time required is proportionate tothe diameter of the broken bone. The phalanx ofa finger may unite firmly in four weeks, and it mayrequire six months to accomplish the same result ina fracture of the femur. It is dangerous practiceto remove retentive measures too early,more partic-

9

ularly in fractures of the humerus and femur; care-lessness in this regard has frequently been punishedby formidable deformity arising from yielding ofimperfect callus. Non-union may follow a fractureeither when the reparative material fails to be pro-duced, or when the broken ends are placed and keptin a position which renders it physically impossiblefor the callus to unite them. For the first cause thesurgeon can never be held accountable, as it is al-ways owing to complications attending the injury,or defective nutrition in the patient himself. Thesecond cause may arise from: 1. The location ofthe fracture. 2. Want of co-operation on the part ofthe patient. 3. Ignorance, carelessness, or negli-gence on the part of the surgeon.

Fractures located within joints are very fre-quently followed by non-union, not so much on ac-count of unfavorable anatomical and physiologicalconditions, as from the difficulties encountered inmaintaining accurate and perfect co-aptation for asufficient length of time. The means at our com-mand are not adequate to meet successfully thenecessary indications.

Except in fractures within joints, pseud-arthro-sis is most likely to occur after fractures of thehumerus, femur and ulna.

In private practice the removal of the second causeis often beyond our control. The more refractorythe patient the more unremitting and careful mustbe the treatment. The sux-geon must always be onhis guard to make the first examination thorough,to enable him to arrive at a correct diagnosis. Dis-regard of this rule has oftexx been followed by un-pleasant consequences for the patient and the sur-geon. A diagnosis to be satisfactory must establish:1. The existence of fracture. 2. The seat of frac-ture. 3. The presence or absence of complica-tions. 4. The fact that no soft tissues intervenebetween the broken ends of the bone.

Should any doubt exist in the mind of the sur-

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geon, either in regard to diagnosis or the adoptionof a certain course of treatment, it must be consid-ered not only prudent but necessary to call in earlycounsel, for the benefit of the patient and the pro-tection of the attendant. The best possible protec-tion against mal-practice suits is to treat everycase as though you were expected to defend yourtreatment in court. The following are the princi-pal causes which have been enumerated as givingrise to false joints:

' Rachitis, Syphilis,Scorbutus, Acute febrile affections,Wasting diseases, Pregnancy,Prolonged lactation.

General

Interposition of soft tissue bet. fracture,Separation of fragments,Imperfect immobilization,Imperfect circulation from concomitant

swelling, too tight dressing or position oflimb,

Obliquity of fracture,Complication of fracture.

Local

I have not enumerated old age as a cause for de-layed or non-union. Statistics show that theseaccidents are found almost exclusively in youngpeople at the age of twenty to thirty-five years.With the exception of joint fractures, fracturesunite promptly and in a short time in the aged.Senile osteo-porosis may be considered a favorablecondition for a callus formation.

A great diversity of opinion prevails among sur-geons in regard to the influence of general condi-tions on the production of callus. Some claimthat non-union is almost invariably due to generalcauses. I recollect very well the remark of Ge-heimrath von Nussbaum on this subject. In a lec-ture on this subject he claimed that nearly all, if notall fi’actures, that fail to unite by bone occur in pa-tients suffering from some constitutional taint,more especially syphilis. He referred to severalcases where no attempt at union took place underthe most favorable local conditions, and where

11

a course of mercurial inunction was promptly fol-lowed by bony consolidation. I recollect at leastone case where a false joint was threatened in a pa-tient where the fracture occurred during preg-nancy.

Case 11. Fracture of ulna during pregnancy; de-layed union; Dumreicher’s treatment; cure.

The patient fractured the ulna at the junction ofthe middle with the upper third. She was preg-nant six months with her fourth child. There wasno difficulty in reducing the fracture, or in main-taining co-aptation with the customary dressing.The production of callus did not appear in a satis-factory manner, and ten weeks after the accident Ifound on careful examination free motion of onefragment on the other. I now rubbed the frag-ments freely togetherand applied von Dumreicher’sdressing for hastening the production of callus,making pressure above and below the point of frac-ture by means of four small compresses. Thespace between the upper and lower compresses di-rectly over the seat of fracture became oedematousin a few days, which was soon followed by a massof callus, and bony consolidation was completeabout the time of delivery.

While it is impossible to deny the influence ofgeneral causes in interfering with normal callusproduction, I would array myself on the side ofthose who make diligent search for local causes inevery case of non-union. For the purpose of pre-venting such an unfavorable issue, it is advisablefor the surgeon to bear the following points in mindin any fracture where such an occurrence might fol-low :

1. To satisfy himself that the broken surfaces arein contact. 2. To insure a free circulation in thepart by avoiding tight dressings, and placing thelimb in a proper position. 3. To avoid frequentdressing. The fractured limb should be inspectedoften, but the fragments when in proper place

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should be disturbed as little as possible untilunion has taken place. Frequent change of dres-sing is meddlesome surgery, and will be certain toprove not only unnecessary but possibly harmful inthe end.

Delayed union calls for local stimulation byexternal friction, change of position of limb, orrubbing the fragments together. Dumreicher’sdressing can always be applied with advantage inthese cases. Non-union can be said to have oc-curred after the usually alloted time for bonyunion to take place has elapsed, and the treatmentinstituted for delayed union has been found una-vailing. As regards time, no fixed rule can beadopted. In some cases we may be able to satisfyourselves after three or four months that no unionwill take place, and on the other hand cases havebeen reported where union took place a.year and ahalf after the accident.

From a pathological stand-point we may distin-guish four principal varieties of false-joints.

1. Ends of fragments atrophied, no connectingmedium. The fragments may point directly to-wards each other, but separated by an interval, orthey may overlap each other, and still in other in-stances they may be separated byan interposingband of the surrounding soft tissues—muscle,fibrous tissue, tendon, ligament, etc.

2. Ends of fragments atrophied but united by abridge of connective tissue. In these instancesthe functional result is not so bad as in the firstvariety. The usefulness of the limb depends onthe length and thickness of the connecting liga-ment. Nature has made an effort to restore thecontinuity of the bone, but the process has stoppedshort of ossification.

3. Ends of fragments less atrophied—ligamentousunion with isolated deposits of bone. Here theeffort has been in the right direction, but the resultimperfect.

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4. Ends of fragments not atrophied, sometimesenlarged—directly opposite each other flattened orslightly rounded, connected by a peri-fragmentaryligament. Bone surfaces separated by a synovialsac. These are the exceptional cases where natureinserted the anatomical elements of a true joint inlieu of a bony callus.

The diagnosis of a false joint is not attended byany difficulty. A false point of motion at the seatof fracture at a time sufficiently remote from thetime the injury was received, when we can reasona-bly assume that the process of repair has been ar-rested, is all that is required to establish a diagno-sis.

Excluding from consideration non-union of joint-fractures, it can be said that the prognosis dependson two things: 1. The time that has elapsed sincethe injury was received. 2. Amount of separationand degree of atrophy of ends of fragments.

It can be stated as a rule that the greater the in-terval between the injury and the operative pro-cedure, the greater the atrophy of the limb and thebone ends, conditions which seriously affect ourprognosis.

The treatment, so far as it has for its object therestoration of the anatomical defect, belongs ex-clusively to the domain of operative surgery. Insome instances a false joint does not materially in-terfere with the function of the member; in othercases, whei’e an operation is not deemed advisable,some form of an apparatus can be applied whichwill act as a substitute for the defective bone. Inselecting from the operations which are usually re-sorted to in the treatment of false joints,we shouldbe careful to ascertain as nearly as possible theexact local conditions at the seat of fracture. Allmethods of treatment aim at: 1. Production ofosteo-plastic inflammation of the fractured ends ofthe bone. 2. Accurate coaptation.

Inter-fragmentary injections. This form of treat-

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ment is indicated when the fragments are in closeapposition, the ends of the bone not much atro-phied and the treatment not too distant from thetime of injury. The operation is done with a Pra-vaz syringe with a sufficiently long and stout needle.As injection fluid, lactic and acetic acids appear tohave yielded the best results. Hueter recommendslactic acid for this purpose in strong terras. He isof the opinion that this substance has a specific ac-tion in exciting osteo-plastic inflammation in bone.The injection should be made between the bone-ends, and the fluid made to permeate the wholespace between them. Like some of the other op-erations, this procedure may be repeated everyweek or two should signs of reaction appear, inas-much as the measure is harmless and not attendedby much suffering.

Subcutaneous incision. This little operation canbe done under the same circumstances as the pre-ceding one, and consists in passing asmall tenotomesubcutaneously down to the seat of fracture, divid-ing any fibrous bands that may exist between thebone, and scarifying the bone-ends.

Acupuncture. A stout steel needle is passeddown to the seat of fracture, and by moving thepoint in different directions the intervening spaceand the bone-ends themselves are punctured withthe instrument.

Electro-puncture. An electric current is passedthrough acupuncture needles. This method offersno special advantages.

Seton. Introduced into practice by Physick, thisform of treatment soon received an extensive trialon part of the profession. The dangers attendingits use and the uncertainty in its results very justlycondemn its use at the present time.

Perforation of the ends of the bone. This opera-tion is usually accredited to Dr. Brainard,who in anumber of published articles claimed it as his own.Dieffenbach, however, performed the operation

15

twice in 1841, antedating Brainard’s operation bya number of years. The operation is the one usu-ally resorted to at the present time. If carefullydone it is devoid of danger, and has yielded goodresults. The operation is performed by making asubcutaneous tunnel with a tenotome through thesoft tissues down to the seat of fracture, insertinga perforator of suitable size; both ends of the boneare perforated a sufficient number of times, thenumber of perforations dependingsomewhat on thesize of the broken bone. It is advisable to use aninstrument with a triangular point, as being lessliable to break than one with a flatpoint. The per-forations give rise to osteo-plastic inflammation,and if no interposition of soft parts exists, andthe fragments are in close contact, the operation isusually followed by success. A repetition of theoperation is often necessary.

For the purpose of illustrating the efficacy ofsimple drilling in favorable cases, I will relate thefollowing case :

Case 111. Ununited fracture of femur; drilling;cure. Patient was about forty-five years of age,and had suffered from compound fracture of femurat the juncture of the lower with middle third.Wound healed promptly. Fracture treated by ex-tension. At the end of nine weeks it was foundthat no union had taken place, and the attendingsurgeon was promptly sued for mal-practice, and ajudgment for $4,000 recovered against him. I sawthe man five months after the injury, and foundfalse point of motion at the seat of fracture. Thelimb was shortened two and one half inches, thefragments overriding in such a manner that the up-per fragment could be felt anteriorly and towardsthe inner side, while the lower fragments, appa-rently much atrophied, could be found posteriorlyand towards the outer side. The upper fragmentappeared to be covered with callus. The fragmentswere freely and forcibly moved upon each other.

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A perforator was introduced from the outer aspectof the thigh, and at least five perforations weremade through the same opening in the skin and tra-versing in different directions some transfixingboth ends of the bone. The limb was dressed asfor recent fracture, with eighteen pounds of weightfor extension.

Bony union was complete two months after theoperation.

Introduction of ivory pegs. This operation wasdevised byDieffenbach after he became dissatisfiedwith simple perforation. The operation is per-formed in a similar manner, only that ivory pegsare driven through the perforations into the interiorof the bone, and allowed to remain until a suffi-cient amount of inflammation has been excited. Itwas urged by Brainard against this operation thatforeign bodies introduced into bone do not give riseto an increase of tissue formation, but that, to thecontrary, they produce destruction and absorptionof bone. Clinical results and experiments on thelower animals, however, have sufficiently demon-strated the fallacy of this assertion. In numerouscases where simple perforation proved useless,Dieffenbach’s operation was followed by success.In my experiments on animals I have invariably ob-served osteo-plastic inflammation of the bone alongthe track of iron, bone or ivory nails, provided theforeign body was introduced under antiseptic pre-cautions.

Nailing of fragments. In cases of very obliquefractures, or when the fragments override eachother, the object to be accomplished can be reachedwith more certainity if the perforations are madeto transfix both fractured ends, and, by driving inabsorbable aseptic bone nails, the fragments aresecurely fastened together. This operation com-bines all the advantages of Brainard’s and Dieffen-bach’s operations, and at the same time securesaccurate coaptation and immobility. Yolkmann

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has modified this operationby removinga rectangu-lar piece of bone from opposite sides of each frag-ment, and, after fitting the surfaces accurately to-gether,transfixing them by two ivory nails. Thisoperation furnishes a large surface of bone, and se-cures accurate apposition and perfect immobilitybetween fragments. Aseptic bone nails should beused in preference, and they should never be al-lowed to project beyond the surface of the bone.If introduced antiseptically they will be absorbedcompletely after they have accomplished the objectof their introduction.

Case IV. Fracture of ulna ununited; subcutane-ous nailing of fragments; cure.

J.A., aged twenty-five; fractured both bones of thefore-arm six months ago. Radius united with con-siderable exuberant callus. Ulnar fragments ingood position, false point of motion near the mid-dle of the hone. Made a very oblique perforationthrough both fragments with a small drill andnailed the fragments together with a bone nail.About two weeks after the operation considerableswelling appeared at the seat of fracture, motionbecame less and less, and two months after opera-tion bony union had taken place. The nail was notseen after the operation.

Resection of bone ends. This operation was firstperformed in the year 1760, at the suggestion ofMr.'‘White, of Manchester. It found ready adop-tion, and was frequently performed by English andContinental surgeons. It soon, however, becameevident that it was not devoid of danger, and beforethe introduction of antiseptic surgery it had falleninto well merited disrepute. It necessitates theconversion of a simple into a compound fracture,with all its dangers. The great advantages of anti-septic surgery are rendered peculiarly prominent inthis connection, inasmuch as the surgeon makes thefracture compound during the operation, but makesit again simple after its completion. This opera-

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tion is the only one which promises success incases where the fragments are separated by inter-position of soft parts; again, where the fragmentsarej excessively atrophic, or are widely separatedand cannot be brought into appositionby any othermeans; likewise in cases where anew joint hasformed. The important rules to be observed in thisoperation are: 1. To save the periosteum. 2. Toprocure as large a bone surface as possible. 3. Toremove carefully all interposed tissue. 4. To se-cure apposition and immobility by wiring or nail-ing the fragments together.

As the fractured ends are usually tapering andatrophied, and the medullary canal closed for somedistance, it is unavoidable, for the purpose of sav-ing bone tissue and at the same time procuring alarge surface for apposition, to make the bone sec-tion, obliquely, or Yolkmann’s “step” resection. Ithas been said in opposition to the silver wire suturethat it is very apt to cause necrosis, and every onewho has used it can testify to the difficulty in re-moving it. To obviate these difficulties it has beenproposed to transfix both fragments with a gimlet,and leaving the instrument in situ fasten the frag-ments with a figure of 8 silver wire passed over thepoint and the proximal side of the gimlet. Whenthe gimlet is removed the silver wire ligature fallsoff. The best material for fastening the fragmentstogether are aseptic bone nails.

If the bone section is made oblique, or rectangu-lar, the fragments can be transfixed by two bonenails. If the bone section is straight, transfixion canbe accomplished by one very oblique nail, or whatis still better, by making a perforation in the axisof the bone from the middle of each resected end,

and fastening them together by a bone nail. If thediameter of the bone is large, more than one nailcan be used in this manner. The following caseis reported for the purpose of illustrating theobstinacy of some of these cases in resisting allkinds of treatment:

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Case V. Pseud-arthrosis humeri; resection andwiring; failure.

This patient was twenty years of age, and frac-tured the humerus two years before he came undermy observation at the Milwaukee Hospital. Thearm and fore-arm were perfectly useless and verymuch atrophied. On examination it was foundthat the fracture had taken place about three inchesabove the elbow-joint. Rubbing the fragments to-gether and perforation had been repeatedly per-formed without any evident success.

Under the influence of an anaesthetic an incisionwas made over the outer aspect of the arm, care-fully avoiding the musculo-spiral nerve. The frag-ments were loosely connected by a ligamentousband and extremelyatrophied, especially the lowerfragment, which for some distance did not exceedthe diameter of an ordinary lead pencil. The peri-osteum was reflected, and the intervening tissuewith the bone ends freely excised, and the frag-ments brought into apposition with a silver wiresuture

This operation was performed before antisepticsurgery came into general use, hence the reactionwas quite severe. A fenestrated plaster of Parissplint was applied. The inflammationabout the seatof fracture, however, did not appear to affect thebone, which evidently remained in the same atro-phic, indolent condition. After several months ofpatient treatment, the wire was removed, but noimprovement appeared to have taken place, and asthe patient refused further operative measures hewas discharged from the hospital.

In this case the patient blamed tight dressings forthe bad result, and the atrophied condition of thewhole member, and a tight circular bandage hebrought with him to the hospital would tend tocorroborate this opinion.

Case VI. Pseud-arthrosis humeri; resection;wiring; partial success; Dieffenbach’s operation;bony union.

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The patient, a young man in good health, hadfractured the humerus about eighteen months be-fore the operation. The fore-arm was extremelyatrophied and perfectlyuseless. The extensor mus-cles were paralyzed. Fracture at the junction ofthe middle with lower third. As all the ordinarymeasures had proved unsuccessful in the hands ofothers, resection and wiring the fragments to-gether was done as offering the only prospect fora favorable issue. The bone was again approachedby an incision made over the outer aspect of thearm. The fragments were found atrophied andseparated by a mass of connective tissue. Thebone ends and interposed tissues were freely re-moved, and the fragments wired together. Theoperation was done under antiseptic precautions,and no undue reaction followed. The wire wasremoved about six weeks after the operation;unionhad commenced but was not firm. On two differ-ent occasion subsequently, a sharp silver-plated-metallic nail was driven into each fragment, whichfinally resulted in firm bony union.

A few words in regard to pathological fractures.Writers and teachers unite in asserting that frac-tures arising from pathological causes usually failto unite. While this assertion holds true as far asfractures are concerned which arise from neoplas-tic (cancer, sarcoma) deposits in bone, it certainlydoes not apply to spontaneous fractures, whichsometimes occur during inflammatory affections ofbone. To illustrate I will.report only one case outof a number which have come under my observa-tion;

Case VII. Acute osteo-myelitis of femur; sponta-neous fracture; bony consolidation.

The patient was a lad nine years of age, sufferingfrom acute diffuse osteo-myelitis of the femur.An abscess was opened over the middle and outeraspect of the thigh four weeks after the firstsymptoms had shown themselves. Two weeks

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subsequently,on dressing the limb one day, I ascer-tained that the bon% had given way about its mid-dle. Extension by weight and pulley was appliedand sand-bags were placed on each side of the limbto prevent eversion. Suppuration continued pro-fuse for a number of weeks, but firm bony unionhad taken place three months after the accident oc-curred. Two years later I removed almost theentire shaft of the femur,which was found includedin a thick and strong involucrum. The new femuris slightly curved at its middle with the concavityinward, and is at present (six years after fracture)a full inch longer than the opposite one. In someof these cases the recuperative powers of vis medi-catrix naturae are truly wonderful, the same agen-cies which have been the cause of destruction beingin turn utilized in the process of reconstruction.